The influencing factors of the quality of medical record homepage and the application of quality control management plan
10.3969/j.issn.1671-332X.2025.03.015
- VernacularTitle:病案首页质量的影响因素及质控管理方案的应用
- Author:
Yanling WEI
1
Author Information
1. 玉门市第一人民医院 甘肃玉门 735211
- Publication Type:Journal Article
- Keywords:
Quality control management plan;
Quality of medical record homepage;
Clinical efficacy
- From:
Modern Hospital
2025;25(3):385-387,392
- CountryChina
- Language:Chinese
-
Abstract:
Objective To analyze the influencing factors of quality control on the first page of medical records and the application of quality control management plans.Methods Quality control was conducted on the first page of 1 000 medical re-cords discharged from our hospital in December 2023.The results of the quality control were used as the basic data for the control group(traditional management).Based on the problems identified during the quality control,influencing factors were identified,and a quality control management plan was proposed.After communication with physicians and medical record department quality control personnel and promotion of the improvement plan,the plan was implemented.During the implementation process,the im-provement plan was adjusted according to new problems at any time.After applying the quality control management plan for six months,the first page of 1 000 medical records discharged in August 2024 were quality controlled,and the results of the quality control were used as the observation group(comprehensive quality control management plan).Comparison effect.Results Be-fore management,the unqualified rate of the control group was 22.30％.After management,the unqualified rate of the observa-tion group was 10.10％.The unqualified rate of the control group was significantly higher than that of the observation group,and the difference was statistically significant(P＜0.05).The observation group had a higher accuracy rate in filling in the main di-agnosis and the main surgical code than the control group,and the difference was statistically significant(P＜0.05).Conclu-sion The comprehensive control and management scheme can effectively reduce the incidence of problems on the home page of medical records,with remarkable results.
